P1834MONITORING ANTICOAGULATION IN PEDIATRIC PATIENTS ON REGULAR HEMODIALYSIS: CAN A DREAM COME TRUE?

Abstract

Abstract Background and Aims Anticoagulation in hemodialysis aims at preventing the activation of coagulation cascade during the procedure. Appropriate anticoagulation for hemodialysis (HD) requires a precise balance between under- and over-heparinization to prevent extracorporeal circuit (ECC) clotting and bleeding, respectively. This type of balance is practiced in hemodialysis centers, on daily basis, depending on each center’s experience and tailored to every patient, rather than in accordance to a clear guideline. Our aim was to objectively evaluate the adequacy of heparin therapy used for anticoagulation in pediatric patients on regular hemodialysis. Method A follow up observational study for 12 months including 44 pediatric end stage renal disease patients on regular hemodialysis through an A-V fistula or an A-V graft. We excluded patients with a known bleeding disorder, chronic liver disease, thrombophilia, vasculitis or receiving anticoagulation for any condition. All patients were subjected to thorough history taking including dialysis history, assessment of dialysis adequacy by calculating Kt/V and blood pressure monitoring before, during and after session. Clinical evaluation of anticoagulation was done through visual inspection of extra-corporeal circuit, observing transmembrane pressure and recording the duration of compression over the puncture site at the end of the hemodialysis session. Biological monitoring was done by Bedside Activated clotting time (ACT) test. Results On initial evaluation of patients, 11 cases had either clotting or bleeding clinically (only 4 had abnormal ACT values), being on either hemodialysis (HD) or hemodiafilteration (HDF) and receiving unfractionated heparin (UFH) either as a bolus or through a pump. They were further evaluated after being put; on HDF and a heparin pump and showed neither clotting nor bleeding though 2 cases had prolonged predialysis ACT values. On HDF and heparin bolus, no bleeding or clotting were detected though 3 cases had abnormal predialysis ACT values. On HD and heparin pump no bleeding or clotting were detected, 2 cases had low kt/V, a case had abnormal ACT values (5 minutes, 1 hour and at the end ACT values). Conclusion Hemodialysis mode, rather than method of heparin delivery, had a bigger impact on correcting clinical defects of anticoagulation in our patients. ACT as a bedside test of anticoagulation adequacy during HD sessions did not offer extra benefit over clinical evaluation, which is still considered a more accurate method.